Optimal pre-end stage renal disease (pre-ESRD) care involves the early diagnosis of chronic renal failure (CRF) and the use of interventions to delay it's progression. Recent evidence suggests that the quality of pre-ESRD care in the US is sub- optimal. The proposed research project will evaluate certain factors potentially associated with sub-optimal care and their impact on clinical outcomes and cost. The specific aims of this project are: 1) Determine the prevalence and predictors of timing of nephrology referral; 2) Determine the clinical outcomes and cost associated with late nephrology referral; 3) Determine functional status at the initiation of dialysis, and the factors associated with and consequences of poor functional status at initiation of dialysis and 4) Determine the patterns of care of patients with CRF in the Northeastern region of the US. Cross-sectional and retrospective studies will be performed. The data to evaluate referral pattern and outcomes will be obtained from the United States Renal Data System (USRDS), which are already available to the PI. Data to evaluate the effect of poor functional status and the patterns of care among CRF patients will be collected from patients at New England Medical Center, St. Elizabeth's Hospital and from private clinics in the Northeastern region of the US. The results of this study are expected to influence policies and provide insights for strategies to improve the outcomes of patients with chronic renal failure.